No. 2216.

FEBRUARY 17, 1866.

LectureON

THE TREATMENT OF CHOLERA

Delivered at the Royal Victoria Hospital, Netley,

BY DEPUTY INSPECT.-GEN. MACLEAN, M.D.,PROFESSOR OF MILITARY MEDICINE.

(Concluded from page 114.)

I HAVE felt it to be my duty to speak distrustfully of manymethods of treating cholera which have lately been urged onthe attention of the profession and the public. Many of them,if you will excuse a homely metaphor, are the cast-off clothesof Indian practitioners brushed up to look like new. " OldIndian" doctors know them well, and make a present of themto their new and complacent wearers without a sigh. Well,gentlemen, I know no " cure" for cholera. What is more, I

suspect we are never likely to see one. Nevertheless, I be-lieve we shall in time extinguish cholera as we have, in thiscountry at least, extinguished plague. This is one of the cer-tain triumphs that await the slow progress of sanitation. Itis probable that a whole generation of obstructives must passaway before even the initiatory steps in this great movementare likely to 1?e taken. We have sanitary commissions in allthe great Presidency towns of India; but they are without thenecessary authority to act in an effective way, and, in omeinstances, very notably in Madras, the whole weight of thosein power is exercised to obstruct the efforts of the commis-sioners for the public weal. We are not very much better offat home. Men ignorant or indifferent in such matters aboundin high places, and in almost every municipal body in thekingdom trading selfishness and apathy prevail to the detri-ment of the public health. It is now time for me to point outwhat can be done for the benefit of those who are smitten withthis disease. Although I know of no cure for cholera, I amquite sure that, by good and judicious management, we canrescue a great many who, without this, would inevitablyperish.

1. You will endeavour to secure for your patients the besthygienic conditions possible under the circumstances in whichyou may be placed. In India, if that be possible, treat yoursick in tents, and avoid overcrowding them.* *

2. It is incumbent on you at the outset of any epidemicvisitation to look a little ahead, and so to arrange the dutiesof your attendants and assistants as not to exhaust theirstrength and energies in the first few days. I have seen greatmischief and confusion result from want of attention to this.The first sufferers who come in under such a system are wellcared for; while those who come last are neglected from in-ability on the part of the attendants to hold out any longer.

3. The next point is to have arrangements made, first, forthe disinfection; and, secondly, for the removal of the excre-tions of the patients. If this be not done, the tents or hos-pitals, if a large number of patients are under treatment, willsoon be filled with bed and body linen saturated with choleradischarges. The attendants, unless prevented, will empty thevessels containing the stools as near to the tents or hospital asthey dare. As a disinfectant, Dr. Budd, of Bristol, proposeschloride of zinc; but, whatever the agent, disinfected theyshould be, and on no account ought the evacuations of the sickto be emptied into the latrines or waterclosets used by thehealthy. They should be buried in deep pits strongly chargedwith disinfecting agents. All soiled linen should in like mannerbe disinfected, and then plunged into boiling water outside thebuilding or tent. The last case of cholera that occurred in thegarrison at Malta, in the late epidemic, was that of a womanwho had stolen a chemise, the property of one who died of thedisease. She put on this fatal shirt, probably soiled withdischarges, and certainly unwashed, many days after the death

* Dr. Morehead objects to this, but, as it appears to me, without sufficientreason. When cholera prevails in an epidemic form, the ordinary hospitalaccommodation is not enough for our purpose, without exposing the sickfrom other causes to great discomfort and peril, to say nothing of other Ireasons.

of its former possessor, took the disease, and died. I mentionthis instructive fact on the authority of a letter from my friendInspector-General Anderson, principal medical officer at Malta.

4. The next point is to look well to what Sydenham wouldhave called the "constitution" of the epidemic with whichyou have to do. I have never seen any two exactly alike. Atone time you will see the majority of the cases characterisedby vomiting, excessive purging of rice-water stools, with dis-tressing cramps ; at another, you will find cramps absent.Again, you will observe that there is little purging, but ex-cessive action of the skin; or (most fatal form of all) littlepurging, vomiting, or exudation from the skin, the sufferersdying almost before there is time for any of the well-knownsymptoms to be developed-the disease, as Magendie expressedit, "commencing with death. Nothing can more clearly showhow futile it is to expect a cure by merely " restraining theevacuations;" for, as I have just explained, the most fatalform of the disease is that in which there are no evacuationsat all.

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5. When first I went to India it was a common practice towithhold water, especially cold water, from cholera patients.A cruel and pernicious proceeding. The objection was, thatit increased vomiting, and so exhausted the sufferer. Follow-ing the routine of the day, I have acted in this way; and Iwas taught by personal experience the folly of this article ofprevailing medical belief. When a person has been drainedby an hour or two of rice-water purging, the desire for wateris urgent-instinctive: the system craves it as the " hartpanteth for the water-brooks." " Do not, then, be guilty of thecruelty of withholding water; give it often, and give it cold.Hot drinks are not relished by cholera patients. There is nonecessity to give large draughts; but let not the fact that aportion of almost every supply is vomited lead you to withholdit entirely. If you have a supply of ice at hand, let yourpatients have as much as they please. I never saw a cholerapatient to whom ice was not grateful.

6. Is it a judicious measure to apply heat externally: tocover your patients up with blankets; to stimulate the surfacewith counter-irritants, mustard, turpentine, and such like? îWell, I have done all these things, and seen others do themagain and again. Yet I question whether much is gained bythem. I am quite sure that they are very distasteful to ninepatients out of ten. But you will say, Patients are not goodjudges of what is good for them. Perhaps not. Still, Ithink physicians gain something in many diseases by attendingto the instinctive promptings of their patients. I know it is soin the matter of drink in cholera; and I think in the matter ofclothing and external heat we should follow this rule-wherethey are grateful to the patient they should be used, but, ac-cording to my judgment, they ought not to be persisted in ifthe reverse. I have not seen many cases of cholera in England,but I think I have observed greater tolerance of "blanketing"than in India. In Asiatics, the dislike to anything of the kindin this disease is universal. Mustard poultices are almost in-variably applied to the epigastrium in cholera, and also to thecalves of the legs. Sometimes they are beneficial; I do notthink they can be hurtful.

7. Cramps are best relieved by the use of chloroform, givenin doses of five or six minims in a little water ; and if vomitingbe excessive, a little may be sprinkled on a pad of lint coveredwith oiled silk or gutta percha tissue, and applied to the epi-gastrium ; or spongio piline may be used for the purpose. Ihave used chloroform in this way, both externally and in-ternally, very freely, and always with good effect. I have alsoseen a large dose of an alkali, the sesquicarbonate of soda orthe bicarbonate of potash, instantly relieve the spasms, as wellas mitigate vomiting.

8. No remedy has been more used, I should rather sayabused, than opium. Most Indian practitioners have aban-doned it as treacherous and dangerous. I must earnestlycaution you against its use. In the stage of collapse, if it isretained, it is, it must be, useless. But when reaction sets in,the opium, previously inert, begins to act, and is at once aserious hindrance to the restoration of the secretions, and, ifthe quantity given has been large, often hastening on cerebralsymptoms ending in coma. These are its dangers, without, sofar as I know- or could ever discover, a single compensatingadvantage.

9. What of astringents ? No class of remedies have beenmore used in cholera. The great anxiety has ever been "torestrain the evacuations." Yet I am persuaded that the merepurging rarely kills ; and, as I have already said, in the mostfatal form of cholera there is no purging, or very little. Gravesrecommended acetate of lead with opium, and this combina.

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tion has been more used than perhaps any other remedy in 11. Stimulants, both of a medicinal and alcoholic kind, havecholera. Sometimes capsicum is added by way of a stimulant, been much resorted to in cholera, and very naturally. TheHere, again, we are met by the old difficulty : what service prostration of the powers of both circulatory and nervouscan we expect from such combinations during the condition of systems is so extreme that we cannot wonder that strenuouscollapse ? Very little, I fear. And what is likely to be the efforts have been made to rouse and to sustain them by theaction of large quantities of this powerful sedative during the free use of remedies of this class. Yet I think that those whostage of reaction ? Will it aid or embarrass the struggling have used them most, if observant and candid men, must ad-system ? Again, supposing the remedy to be retained and to mit that they have not answered their expectations; and atact, how far do we benefit the patient by controlling -the least all must allow they require to be given with a cautiouspurging ? I don’t believe that cholera is caused by " hyper- hand. They are useful, as I shall presently show, when given2emia of the nervous centres from heat." If this hypersemia at the proper time and in the right way. I do not think theybe present, there is something else present also, some materies are of any use during the stage of collapse, when at first sightmorbi, some subtle poison-what, I know not, I do not pre- they might appear most appropriate.tend to know. If it be the case, as so many suppose and as I We have thus examined the therapeutic value of the reme-believe, that this poison is in part at least eliminated in the dies that have been most used in cholera. The result is notintestinal canal, how far do we benefit our patient by restrain- encouraging. I may say I have tried most of them, and theing it ? I have ridiculed the attempt to secure this object by above is the result of my experience. You will perhaps say-mechanical means ; will the use of astringent drugs stand the Do you then advise no treatment in cholera at all ? Well, Itest of argument any better ? But then experience has sanc- can only say that in the collapsed stage I know no drug worthytioned them. Alas ! I have had much experience, and I am of the smallest confidence. Must we, then, abandon oursure that I was more successful, as a rule, when I withheld patients to nature, and do nothing ? Must we suffer them tothem. Still, there are cases where some astringent is neces- die without an effort to save them ? My answer is, that effortssary. Granting that the purging within certain limits is of the kind described above are futile ; your remedies are

salutary, it may go on to such an extent as to lower the patient either vomited, or, if retained, are inert, and if given, as theyhopelessly. In such cases an effort must be made to restrain often are, in excessive quantities, they become a serious sourceit. Acetate of lead should then be used, in solution, but with- of embarrassment, interfering above all with nutrition. Ifout opium. In such cases pernitrate of iron, in full doses, opium, the preparations of lead, or calomel, have been ab-might be tried. My friend Surgeon-Major Mudge, of the stained from, Nature, in the stage of reaction, starts, so toMadras Army, made a trial of turpentine in egg emulsion with speak, fair, which I am sure is not the case when weightedan aromatic, and in a number of cases found it more than with one or other, or, as I have often seen, with all the above.answer his expectations. The sufferers in whom Dr. Mudge Because I objected to bleeding intemperate old soldiers oftried it were all Asiatics. It does not seem to have caused twenty years’ service in tropical and malarial climates, takingvomiting or even nausea-the objection to which we might ex- blood away to the extent of upwards of a hundred ouncespect to find it open, as turpentine is generally a nauseous medi- when suffering from peri-hepatitis, I was called the other daycine. In one epidemic I found nitrate of silver exceedingly "t-oMicawber of medicine," the gentleman "who waits touseful as an astringent in excessive purging, particularly, as I see flat will turn up." Well, I don’t object to the name innoted at the time, in children; some of my native pupils used the least; I had rather be the" Micawber" than the " San-it extensively during the same epidemic in the great native grado" of modern medicine. The more I have " waited" uponcity of Hyderabad, and with so much success as to gain for Nature, the less I have attempted to force her, the more I havethemselves considerable reputation. I used it again in the found that " something" is pretty sure to " turn up" to thefollowing year, with disappointing results-another proof of advantage of my patients. Very notably has this been thethe "varying constitution of epidemics." " case in cholera. Some-unfortunately a great many-patients

10. Calomel has been used to fulfil every indication in turn, in severe epidemics will die, but such cannot be saved byaccording to the peculiar belief of the prescriber. Some give it pouring drugs into them in the collapse of this terrible disease.as a purgative, others as a sedative, not a few "to stimulate Suffer me to recapitulate. Secure the best hygienic con-the secretions." I have seen it given as a cure for vomiting. ditions possible for your patients; avoid crowding them; giveThen we have a pretty numerous class who give it for no reason abundance of water to drink and ice to suck ; correct crampsin particular. Calomel is the trump-card in their hands; so, and inordinate vomiting by the internal and external use oflike good whist-players, "when in doubt," as men are apt to chloroform; apply external warmth and extra bedclothes ifbe in dealing with cholera, they "play trumps"-they give these are grateful to the patient, but if they make him rest-calomel. I have seen it given in every conceivable way, and less do not press them. If the cuticular discharge is excessive,for every possible or impossible end : in grain doses every hour wipe the patient dry from time to time, disturbing him as littleor half hour, and by heroic practitioners in scruple doses again as possible. If vomiting be not excessive, and if the remedyand again. But, gentlemen, it is the old story. Calomel is of does not excite it, ten drops of the mixture I have recom-no use during the stage of collapse ; but by-and-by, when the mended in the premonitory diarrhcea may be given from timepowers of life begin to revive again after the shock is over, the to time, chloroform being substituted if vomiting be urgent.first thing the system has to deal with and to dispose of is As soon as vomiting ceases, you must support the patient bytwenty or thirty grains of calomel. What results ? Very often proper nutriment. At first I begin usually with thin arrow-vomiting of that "green paint-looking matter" of which I root, well boiled, and flavoured with a little aromatic. I givespoke appears, and you know how hard it is to stop that; or this, commencing with a teaspoonful at a time, giving everybilious diarrhcea is excited, which soon brings the case to an now and then a teaspoonful of brandy in it, never over-dis-end. At the best it disturbs the stomach and interferes with tending the stomach. Instead of water, I now quench thirstnutrition. At such a time Nature needs the helping hand of with milk containing a little lime-water, and flavoured, if itthe physician to sustain and assist her in the life and death be at hand, with a few drops of curagoa. This may be oftenstruggle, instead of being searched and goaded by powerful given to the patient with a little soda-water. As reaction pro-drugs, prescribed no matter with what intention. Called to ceeds, I substitute strong beef-tea, or, better still, essence ofsee a case of cholera a few months ago, I found calomel in meat, using it in the same cautious way-spoonful by spoonfulcombination with opium being "poured in" every hour. I at proper intervals; later still, eggs beat up with a littleventured respectfully to ask the reason why; the patient being brandy, and flavoured as before with curaçoa, is often relished.in a state of collapse, the medicine was accumulating in the The greatest caution is required not to disgust the patient, notstomach like water behind a barrier. "What, I asked, "do to re-excite vomiting, not to over-stimulate, and so to bring onyou expect will be the action of all this calomel when the cerebral symptoms during the febrile reaction. When patientsbarrier gives way, when the functions begin to be restored ’? are thus carefully nursed, it is seldom that reaction is exces-The prescriber was not very sure, thought perhaps it might sive. Nothing but mischief may be expected from over-anxietyhave " a cholagogue action-stimulate the bile." I might have to hasten forward convalescence by too freely pressing foodasked, Is it not conceivable that Nature will do this herself ? and stimulants on the patient. It requires a great deal ofAnd why not stimulate the kidneys as well ? Why concentrate drilling and care to get orderlies and half-instructed nurses toall your attention on the bile ? Is the biliary more in abey- understand this; and many cases go wrong from their over-ance than any other secretion ? and so on. I do not think anxiety to press both on those under their care. In a word,these are impertinent questions. I recommend you to put the treatment of cholera may be summed up in two words--them to yourselves when you are tempted in moments of doubt good nursing. The difficulty is to obtain this when an epi-to prescribe as D’Alembert said we sometimes do-using physic demic rages. The man who in such scenes maintains his pre-as a strong but blind man uses a club in a crowd, hitting sence of mind, preserves order, regularity, and good hospitalfriend and foe with equal impartiality. discipline, and so arranges as to secure to each patient a fair

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amount of this good nursing, will save a larger proportion ofcases than by any other method with which I am acquainted.What I recommend to others I followed in my own case. Whenstruck down by this disease, I took no drugs. I experiencedthe burning thirst I have described; but instead of tormentingmyself by abstaining from fluids, I drank freely of iced soda-water, to my infinite comfort and refreshment. When I

vomited, which I did often, I drank again. A faithful ser-vant, my only doctor, sat by me, and, when too feeble to domore than express my wants by a gesture, replenished my cupagain and yet again. I vividly remember the resolution thenformed, and never since departed from-to do unto others ashad been done unto me; never to withhold a cup of cold waterfrom a cholera patient. With daylight came a kind and judi-cious medical friend, who, instead of goading me with physic,sustained me with food, much in the manner I have advisedin this lecture. With the result I had and have every reasonto be satisfied and thankful. Dangerous reaction-i. e., highfever, with cerebral symptoms and coma, I have seen; butonly when Art, coming not to aid but to thwart Nature, hasinterfered with her eliminatory processes by the too free useof opium, astringents, and such like remedies. Iri such caseswe must have recourse to free purgation by calomel, applyice to the head, and restore the action of the skin by the wet-sheet, cold sponging, and the like. When the..secretion ofurine is long delayed, I have seen good result from the freeuse of chlorate of potash, and the application of turpentinestupes over the region of the kidneys.Note.-Since the above lecture was delivered, I have seen

and read with pleasure and profit Dr. George Johnson’s"Notes on Cholera." This able physician has been led tomuch the same conclusions as to the action of most drugs incholera as are expressed above. Dr. Johnson puts more faithin the action of purgatives than I can do; for, like everyknown class of drugs, they have been freely used in India. I

sincerely trust that Dr. Johnson may never see so many casesof cholera as I have done; but I cannot help thinking, shouldit be otherwise, that he will see cause to believe with me that,in a vast majority of cases, there is quite enough purging with-out artificial aid. Still, for my own part, if again smitten bycholera, let me rather fall into the hands of a pu2-ging than anastringing physician-one who thinks he does you service byretaining what Nature is so solicitous to expel from the system.

THE PROOFS THAT LITHOTRITY IS ANEMINENTLY SUCCESSFUL OPERATION.

BY HENRY THOMPSON, ESQ., F.R.C.S.,SURGEON EXTRAORDINARY TO H.M. THE KING OF THE BELGIANS,

SURGEON TO UNIVERSITY COLLEGE HOSPITAL, ETC.

No. II.

IN THE LANCET of February 25th of last year I published,as proof of the capabilities of lithotrity, which at that timeseemed to me to have been too readily impugned, a statementof every case in which I had crushed a stone during the year1864, amounting in number to nineteen. Some discussion fol-

lowed, and it was said at the close, "Mr. Thompson’s sta-tistics are at present too small for general conclusions," (THELANCET, April 1st, 1865.) I had, however, stated that theoases were not offered as "statistics," but that I had given ayear’s experience for what it was worth. I now present air-

other year’s entire experience of lithotrity-viz., that of theyear 1865, amounting to twenty-four cases more, with thesame view, and I venture to think that it will appear to thereader that this series of forty-three consecutive cases may beregarded as good evidence in support of the proposition placedat the head of this and of the former paper.

I will premise, in the same terms as before, that favourablecases have not been selected for the proceeding. On the con-trary, the only cases during the year in which I declined tooperate by lithotrity were two-one, a large phosphatic stone,weighing upwards of three ounces, in a patient aged seventy-one years, whom I cut, and who is living and well now; theother, an oxalate-of-lime stone, weighing two ounces and aquarter, in a patient aged seventy-three years, whom I alsocut, and who gradually sank a few weeks after the operation.

That there may be no mistake, I shall, as before, in eachcase name at least one individual whose name is known and whohas seen it with me and been present at one or more sittings.Without any fear that the accuracy of my statement would becalled in question, I prefer this method as the best to adopt,since it places the facts beyond the suspicion of error, andwithin the reach of present inquiry.CASE 1.-A gentleman aged eighty-four years. Small uric-

acid calculus. Five sittings: January, 1865. Perfectly suc-cessful. I had the pleasure of meeting in consultation Mr.Solly several times in this case.CASE 2.-A gentleman aged sixty years. He has passed all

his urine by catheter for some years. Jan. 1865: A smallishphosphatic stone ; six sittings. Perfectly successful. Mr.M. B. Hill saw this case for me several times during a tempo-rary absence.CASE 3.-A gentleman aged seventy-five years. Phosphatic

stone, medium size. Seven sittings : April and May, 1865.Prostate large; bladder has not been emptied without catheterfor years. Perfectly successful. This case had the advantageof Mr. Aikin’s constant care and attention.CASE 4.-A gentleman aged sixty-one years. A large uric-

acid stone. Ten sittings : April and May, 1865. Perfectlysuccessful. Dr. A. Simpson of Glasgow, and Mr. M. B. Hill,saw this case several times.CASE 5.-A gentleman aged fifty-nine years. A large phos-

phatic stone; disease of the kidneys. Eight sittings: Apriland May, 1865. Perfectly successful. A patient of Dr. Sharpeof Norwood, who frequently saw him with me.CASE 6.-A gentleman aged sixty-five. Rather small uric-

acid stone. Four sittings: April and May, 1865. Perfectlysuccessful. Seen by Mr. M. B. Hill, also by Mr. Van Burenof New York.CASE 7.-A gentleman aged fifty-three. Uric-acid stone,

medium size. Eight sittings : April and May, 1865. Per-

fectly successful. Seen by Dr. A. Simpson of Glasgow, andby others.CASE 8.-B-, aged sixty-two. Small phosphatic stone.

Three sittings : in University College Hospital April and May,1865. Recovered. About five months after he died of cancerin the bladder. (See Hospital " Mirror," Dec. 16th, 1865.)CASE 9.-A gentleman aged seventy-one. Two or three

smallish uric-acid stones. Nine sittings : in April, May, andJune, 1865. All removed, and greatly relieved, but now atendency to deposit phosphates; removed by washing out thebladder. Often seen by Dr. A. Simpson and others.CASE 10.-B-, aged twenty-eight. Hard phosphatic

stone of medium size. Six sittings : May, 1865; in UniversityCollege Hospital. Perfectly successful. (See THE LANCET,Hospital "Mirror," Dec. 16th, 1865.)CASE 11. -A gentleman aged sixty-two. Rather small uric-

acid stone. Three sittings : May, 1865. Perfectly successful.Seen by Mr. Clover, who gave chloroform.CASE 12.-A gentleman aged seventy-four. Small medium

uric-acid. Four sittings : May and June, 1865. Prostate verylarge. Perfectly successful. Mr. C. King, of Highbury, wasin constant attendance with me.CASE 13.-A gentleman aged seventy. Large uric-acid

stone. Nine sittings: May and June, 1865. Prostate large.Perfectly successful. Mr. M. B. Hill watched this case con-stantly with me. Mr. Clover gave chloroform.CASE 14.-A gentleman aged sixty-two. Medium-sized uric-

acid. Seven sittings : June and July, 1865. Stone completelyremoved. Greatly relieved, but some derangement of the

; bladder continues. Seen also several times by Mr. B. Hill.CASE 15.-A gentleman aged sixty-one. Uric-acid of me-

dium size. Seven sittings : June and July, 1865. This patientwas well known to Dr. Greenhow, who saw him occasionally.

’ Perfectly successful.! CASE 16.-B-, aged thirty-nine. Small phosphatic stone.

Three sittings : June and July; in University College Hospital.Perfectly successful. Sent to me by Dr. U. West, of Alford.CASE 17.-A gentleman aged sixty-nine. Two calculi, me-

dium size ; mixed phosphates and urates. Seven sittings :June and July. Seen with me several times by Dr. Buchanan,of Glasgow. This patient had been cut in Edinburgh threeyears before, and two uric-acid stones removed, but smallerthan the present. Perfectly successful.CASE 18.-A gentleman aged forty-seven. Phosphatic stone

of medium size. Five sittings : September and October, 1865.The patient had been under the care of Mr. Rhind, of Shipley,Yorkshire, who advised him to undergo the operation. Per-fectly successful.CASE 19.-A gentleman aged sixty-five. Uric-acid of large